Individual
LEE BROCK WREN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
715 W JUDICIAL ST, BLACKFOOT, ID 83221-2036
(208) 785-2210
(208) 785-2216
Mailing address
715 W JUDICIAL ST, BLACKFOOT, ID 83221-2036
(208) 785-2210
(208) 785-2216
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
66612099934
UT
152W00000X
Optometrist
Primary
ODP-100148
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1215120696
—
ID
01
—
66612099900001
BLUE CROSS/BLUE SHIELD
UT
05
—
999000797009
—
UT
Enumeration date
08/20/2007
Last updated
09/10/2019
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